Scielo RSS <![CDATA[SA Orthopaedic Journal]]> vol. 17 num. 1 lang. pt <![CDATA[SciELO Logo]]> <![CDATA[<b>Common mistakes when writing the conclusion of a research manuscript</b>]]> <![CDATA[<b>Professional burnout</b>]]> <![CDATA[<b>Comparing outcomes between enhanced recovery after surgery and traditional protocols in total hip arthroplasty: a retrospective cohort study</b>]]> BACKGROUND: Traditionally, hip replacement surgery was associated with prolonged recovery and rehabilitation in a hospital setting. Prolonged stay is causing growing concern internationally, where there is an increased drive to cost-effective practice and a realisation that prolonged hospitalisation is not required and may be detrimental. Enhanced Recovery After Surgery (ERAS) protocols address this problem by advocating evidence-based multidisciplinary peri-operative management pathways associated with rapid recovery, without compromising safety. Despite proven efficacy, these protocols are not being implemented in most South African orthopaedic practices. METHODS: Data from two cohorts (80 patients) undergoing elective primary total hip arthroplasty were included. One group was rehabilitated according to a prolonged stay protocol and the other according to ERAS. Cohorts were matched according to demographics and comorbidities. The functional outcome was compared using the Oxford Hip Score. The 30-day readmission rate was compared to assess the safety of early discharge, and the length of stay of patients was compared. RESULTS: The readmission rate and Oxford Hip Scores showed no clinically significant difference between the cohorts. The length of stay was markedly decreased in the ERAS group. CONCLUSION: ERAS protocols can decrease the length of stay in elective total hip replacement without compromising patient safety or functional outcome. Level of evidence: Level 4. <![CDATA[<b>The Oxford Shoulder Score: Cross-cultural adaptation and translational validation into Afrikaans</b>]]> PURPOSE: The Oxford Shoulder Score (OSS) is a robust and universally utilised shoulder score that has been translated for use in Western and Asian countries. This study aimed to translate, cross-culturally adapt and psychometrically validate the Afrikaans version of the OSS for use in Africa. METHODS: Translation and cross-cultural adaptation was performed in accordance with guidelines in the literature. One-hundred-and-eight consecutive patients with either degenerative or inflammatory pain of the shoulder were prospectively enrolled. Patients were evaluated by completing the Afrikaans OSS, Constant-Murley, quickDASH, and the Subjective Shoulder Value (SSV) scores. Comprehensibility and acceptance, as well as any floor or ceiling effects, were calculated. Reliability was assessed through reproducibility. Internal consistency was assessed using Cronbach's alpha. Validity was determined using a Pearson correlation coefficient between the Afrikaans OSS and the other validated shoulder scores. RESULTS: Comprehensibility and acceptance were excellent, and no floor or ceiling effects were observed. Reproducibility (r=0.99) and internal consistency (Cronbach's alpha = 0.93) were both excellent. Correlation of the Afrikaans OSS with the Constant-Murley and quickDASH was excellent (r=0.84; r=0.81 respectively), and very good with the SSV and Visual Analogue Scale (VAS) pain score (r=0.73; r=0.66). CONCLUSION: The Afrikaans OSS proved understandable, acceptable, reliable and valid. It is an appropriate instrument for use in Afrikaans-speaking patients with shoulder pain from degenerative or inflammatory origin. Level of evidence: Level 3. <![CDATA[<b>Outcomes of intramedullary nailing for open fractures of the tibial shaft</b>]]> AIM: To establish superficial and deep infection rates and time to union of open tibial shaft fractures treated with primary debridement and locked intramedullary nails. MATERIALS AND METHODS: The clinical records and radiographs were retrospectively reviewed of 74 Gustilo-Anderson grades 1 to 3A open tibial shaft fractures that were treated by initial debridement and intramedullary nail fixation over a two-year period. Sixty-three men and nine women with a mean age of 33 years (range 16-67) were followed up for a mean period of 18 months (range 7-32). RESULTS: Sixteen patients (22%) sustained grade 1 injuries, 38 (51%) grade 2, and 20 (27%) had grade 3A injuries. Thirteen patients (18.1 %) were HIV positive. The mean time to surgery was 28 hours (range 8-112). The overall infection rate was 17.6%. Superficial infection developed in 10.8% and deep infection occurred in 6.8%. There was no association between time to surgery and infection rate (0=0.878). There was no association between HIV status and infection p=0.471). There was no association between type of closure and sepsis (0=0.410). The mean time to union was 17 weeks (range 12-50). Five patients (6.9%) had delayed union and one patient failed to unite without undergoing secondary procedures. CONCLUSION: The management of Gustilo-Anderson grade 1 to 3A open tibial shaft fractures with primary debridement and locked intramedullary nailing shows good short-term results with low infection and non-union rates despite delay in surgical management or HIV infection. Level of evidence: Level 4. <![CDATA[<b>Displaced intracapsular neck of femur fractures: Dislocation rate after total hip arthroplasty</b>]]> BACKGROUND: Dislocation is one of the most common orthopaedic complications after primary total hip arthroplasty (THA). The reported dislocation rate in elective THR is 5-8%. This number increases up to 22% for THA done for neck of femur (NOF) fractures. Larger femoral head sizes increase the head-neck ratio and range of motion before impingement, therefore reducing the dislocation rate. Due to the reported increase in dislocation for trauma, some surgeons prefer to do a hemiarthroplasty or open reduction and internal fixation (ORIF) rather than a THA. METHODS: A retrospective review of all THAs done for NOF fractures during 2006 to 2012 was undertaken at a large referral hospital. Records were reviewed for patient-related and surgical risk factors. We excluded all pathological fractures, extra-capsular fractures and failed ORIF. RESULTS: A total of 92 cases were identified as suitable for analysis. Average age at surgery was 73.2 years (range 30-81). Delay to surgery was 5.3 days (range 1-63). Average follow-up period was 18.3 months (range 3 months to 4.3 years). Four patients (4.3%) had a confirmed dislocation. The four patients who had confirmed dislocation had the following characteristics: 28 mm femoral head size, age over 60 years, two posterior approaches and three females, although not statistically significant. CONCLUSION: The outcomes of THA in patients with NOF fractures can be favourable and provide good long-term prosthesis survival. We report on low dislocation rate post total hip replacement for intra-capsular NOF fractures. Level of evidence: Level 4. <![CDATA[<b>Circular external fixation in the management of tibial plateau fractures in patients over the age of 55 years</b>]]> INTRODUCTION: Tibial plateau fractures in the elderly pose significant treatment challenges because of coexisting medical problems, pre-existing degenerative joint disease and osteoporosis. While several studies have reported promising results with the use of circular external fixation, little data is available on its use in older patients. This study aims to compare the complications and union rate of circular external fixation in patients over the age of 55 years with that achieved in younger patients. MATERIALS AND METHODS: We retrospectively reviewed all patients treated with circular external fixation over a six-year period. Patients were divided in two groups: Group 1 consisted of patients under the age of 55 years and Group 2 of patients 55 years and older. Group 1 consisted of 63 cases (mean age 37.2 ± 9.1 years and Group 2 of 16 cases (mean age 60.2 ± 5.8 years). Apart from the patient age, there was no significant difference between the two groups in terms of demographics, mechanism of injury (p-value = 0.9) or the prevalence of polytrauma (p=1.0). RESULTS: At a mean follow-up of 19 ± 6.2 months all but two of the fractures had united. The mean overall duration of external fixation was 20.2 ± 8.2 weeks, with a slightly longer mean time-in-frame in Group 1 (20.9 ± 1.1 weeks) in comparison to Group 2 (17.8 ± 1.4 weeks, p=0.1). Complications occurred more frequently in patients over the age of 55 years (56% vs 37%, p-value = 0.2). Loss of reduction also occurred more frequently in patients over 55 years (19%), compared to patients younger than 55 years (6%) (p=0.1). CONCLUSION: Circular external fixation may be a viable treatment option in patients over the age 55 years who sustain high-energy tibial plateau fractures associated with significant soft tissue compromise. No significant difference was found in terms of the union rate or the development of complications when compared to younger patients. Level of evidence: Level 3. <![CDATA[<b>Epidemiology of traumatic orthopaedic injuries at Princess Marina Hospital, Botswana</b>]]> BACKGROUND: Traumatic injuries pose a significant and increasing challenge to healthcare systems worldwide. One major type of traumatic injury is the traumatic orthopaedic injury, whose epidemiology is unknown in Botswana. The aim of the study, therefore, was to evaluate the age, sex, type, and determinants of traumatic orthopaedic injuries for inpatients at Princess Marina Hospital from August 2014 to January 2015. METHODS: We performed a descriptive study by retrospectively collecting data on age, sex, date of admission, date of injury, date of discharge, radiological investigation, and injury types and determinants from medical records of patients admitted to orthopaedic wards. RESULTS: The median age of patients with traumatic orthopaedic injuries was 33.5 years (n=372). Males were more frequently injured than females, with a sex ratio of 7:3. Fractures were the most common type of traumatic orthopaedic injury (413 injuries, 75.5%). The most common injury determinants were falls (145 patients/39.0%), road traffic accidents (95 patients/25.5%), and assaults (57 patients/15.3%). CONCLUSIONS: Young adult males were the group most affected by traumatic orthopaedic injuries. Fractures were the most common type of traumatic orthopaedic injuries, with falls being the most common injury determinant. These findings may guide efforts to improve healthcare delivery and public health policy. Level of evidence: Level 4. <![CDATA[<b>Range of movement, power and pinch grip strength post flexor tendon repair</b>]]> BACKGROUND: Flexor tendon injuries (FTI) are common hand injuries that pose a challenge to the multi-disciplinary team. Despite being the most researched topic in hand literature, the optimal surgical and post-operative treatment of FTI remains unclear and results after flexor tendon repair (FTR) continue to be unpredictable. PURPOSE: The purpose of this study was to determine the range of movement (ROM), power and pinch grip strength post FTR and to establish factors that may affect these. METHOD: The study was conducted at an academic hospital in Gauteng, South Africa, between January 2013 and September 2015. At one, three and six months post FTR, the ROM of the injured and contralateral finger(s) were measured. At three and six months post FTR the participants' bilateral power and pinch grip strength were also measured. RESULTS: One hundred and twenty-six participants (n=126) enrolled in the study. There was a drop-out rate of 48%, leaving 65 participants that completed six months' follow-up: 41 males (63%) and 24 females (37%) with mean age of 32 years (SD±10, n=65). Out of 65 participants, 2% (n=1) had an excellent outcome, 32% (n=21) a good outcome, 32% (n=21) a fair outcome and 34% (n=22) a poor outcome with regard to ROM. At six months post FTR the average power grip was 60% (SD±25, n=65) of the unaffected hand, while the average pinch grip was 52% (SD±42, n=65) of the unaffected hand. Sixty-eight per cent (n=44) of patients had post-operative complications: the most common complication was tenodesis/ adhesions (25%, n=16), followed by contracture (22%, n=14). Four patients (6%) had ruptures and 11 (17%) underwent further surgery. Factors that had a positive effect on outcome at six months post FTR were: younger age, no associated injury, less duration between injury and surgery, having controlled active motion instead of passive motion occupational therapy protocol, and not having a language barrier. Injury in zone IV was associated with worse ROM and power grip strength than other zones. CONCLUSION: Although there were some promising outcomes, during this period participants did not consistently achieve the good or excellent outcomes that are achieved in some developed countries. Level of evidence: Level 4. <![CDATA[<b>Recent advances in the pharmaceutical manipulation of bone remodelling: the quest for a healthy skeleton</b>]]> INTRODUCTION: Biochemical characterisation of the autocrine, paracrine and endocrine mediators of bone remodelling provides a scientific basis for the development of pharmaceuticals and autoantibodies which could induce a desired skeletal phenotype. The manipulation of bone remodelling in patients at risk for skeletal disease is gaining clinical momentum due to the benefits of maintaining quality of life rather than restoring the long-term dire consequences of skeletal catabolism. METHODS: A narrative review of current literature pertaining to the modes of action of pharmaceuticals and autoantibodies which manipulate skeletal metabolism was performed. RESULTS: Pharmaceuticals and autoantibodies which manipulate skeletal remodelling can be broadly divided into three categories: bone resorption inhibitors, bone formation stimulators and bone resorption and formation modulators. The mechanisms of action of these medications are briefly summarised and reference is made to the relevant pharmaceuticals and autoantibodies available. Level of evidence: Level 5. <![CDATA[<b>Multilevel paediatric idiopathic intervertebral disc calcification: a case study</b>]]> Paediatric idiopathic intervertebral disc calcification (PIIDC) is a rare, mostly self-limiting condition in children that was first described by Baron in 1924. The aetiology is unknown and to date fewer than 400 cases have been described. PIIDC is characterised by calcifications mainly affecting the nucleus pulposus of the intervertebral disc. Most often lesions are located within the lower cervical spine, followed by the thoracic spine. The most common reported symptoms include low grade fever, localised tenderness, torticollis and decreased range of motion of the spine in the affected region. We present a case of multiple level idiopathic intervertebral calcifications in a 12-year-old male. Level of evidence: Level 5